Cardiovascular Risk Reduction in the Extreme Elderly

Abstract

An American Heart Association statement on secondary prevention of coronary heart disease in the elderly reported that 50% of women and 70% to 80%) of men over 75 years have obstructive coronary artery disease. The total direct and indirect costs of cardiovascular disease and stroke in the US for 2007 was around $286 billion and annual costs are projected to rise to over $1 trillion by 2030. Significant emphasis is now placed on prevention and risk factor modification of cardiovascular disease. The proportion of the population aged 85 years and older (the ‘extreme elderly‘) is projected to increase to 151% by 2030. This review focuses on reducing risk in coronary heart disease and congestive heart failure in the extreme elderly. We review modifiable cardiovascular risk factors (hypertension, lipid profile, lifestyle modification), pharmacological strategies (statins, beta‐blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, aspirin) and the available evidence for their use in extreme old age. There is insufficient evidence to reach major conclusions with respect to cardiovascular risk reduction in the extreme elderly. Further trials involving older patients are needed before evidence‐based recommendations can be formulated for this population.

Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease

“…22,23 The optimal pharmacotherapy in these circumstances is unknown, and strict adherence to the guidelines may even result in patient harm. Doctors may be aware of the guidelines but question their applicability to specific patient circumstances.…”

Retrospective evaluation of statin prescription in the elderly

“…However, elderly patients are at an increased risk of developing statin toxicity due to the combination of frailty, sarcopenia and multiple medical comorbidities, and the consequences of toxicity may be severe. While there are no published randomised control trials of statin use in patients above 85 years of age, current available evidence suggests that the magnitude of statin benefits in terms of reducing cardiovascular events and mortality in older patients may only be modest. Up to 80% of a statin's LDL reduction effect may be achieved with 50% of the maximum dose, yet statins, particularly higher‐potency ones such as atorvastatin and rosuvastatin, are often marketed and prescribed at doses up to 40‐fold of their median effective dose (ED 50 ) .…”

“…A comprehensive assessment of an elderly patient's overall function, comorbidities, goals of care and estimated life expectancy is essential when evaluating the need for statin therapy . Hospital admissions provide opportunities for doctors and pharmacists to conduct medication reviews and discuss continuation/alteration of statin therapy .…”

“…23 A comprehensive assessment of an elderly patient's overall function, comorbidities, goals of care and estimated life expectancy is essential when evaluating the need for statin therapy. 15 Hospital admissions provide opportunities for doctors and pharmacists to conduct medication reviews and discuss continuation/alteration of statin therapy. 20 Clinicians should also regularly refer to the manufacturers' product information, pharmacists and drug interaction references, particularly focusing on medications that are potent inhibitors of cytochrome P450.…”

Safe use of statins in elderly people

“…Ageing is often accompanied by functional decline, sensory impairment, frailty, cognitive and renal impairment and multi‐morbidity. Hence, it is important to consider quality of life and life expectancy when prescribing statins in the very elderly . Discuss the patient's wishes, expectations and goals with him or her when making treatment decisions …”